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Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented, trained and evaluated to ensure competence and meet the same health requirements as employees of the hospital.

Findings:

Review of Staff N's personnel file did not have any documentation of hospital orientation or competencies in the education file. Staff A was asked for evidence of hospital training and orientation for Staff N. None was provided.

Dietitian services are provided by a contract. Staff A was asked for the health file for the dietician. None was provided.

On 9/5/13 in the afternoon Staff JJ stated she did not have a health file for the dietitian.

Based on policy and procedure review, hospital document review and interview, it was determined the hospital failed to:
a. Ensure complaints and grievances were appropriately identified.
b. Develop and implement a complete grievance policy.
c. Inform the patient of the internal grievance process.
This occurred in five of five grievances reviewed. (#37, 38, 39, 40 and # 41)
Findings:
1. On 09/03/2013 surveyors reviewed a policy titled, "Patient Grievance Policy and Procedure." The policy and procedure did not clearly define a grievance.
2. On the morning of 09/03/2013 the hospital compliance officer was asked to provide a grievance log to the surveyors. The form provided to the surveyor titled, "Patient Grievance Log", did not contain all the required elements that the hospital's "Patient Grievance Policy" required to be listed on the grievance log.
3. Hospital policy titled, "Patient Grievance Policy," documented, "...a grievance log will be kept by the risk manager which will include: Date of grievance, date risk manager received the grievance, request date for completion of the investigation, investigation completion date, patient first and last name, employee taking complaint, contact number of the complainant, type of complaint, and date report mailed." The form titled, "Patient Grievance log" only contained: Date, date of service, type of complaint, complete investigation date, and date letter mailed.
4. A handout provided to patients at the time of admission titled, "Lindsay Municipal Hospital Conditions of Admission" did not contain information on the hospital's internal grievance process, including requirement of written responses to grievances and time frames for responses.
5. A hospital policy titled, "Patient Grievance Policy and Procedure" documented, "...If the patient or representative is not satisfied with the results of the investigation or the recommended actions, he or she may file a complaint with the Oklahoma State Department of Health," which does not comply with CMS requirements.
6. On the afternoon of 09-03-2013 the compliance officer was asked if she had any further documentation to show that the grievances had been identified, she stated that she did not have any further documentation to identify grievances or any documentation showing the grievance process was followed.
7. This information was provided to the administration upon exit on the afternoon of 09-05-2013. No further information was provided.
8. A hospital policy, "Patient Grievance Policy and Procedure" documented, "...results identifying an opportunity to improve care will be reviewed by the Quality Improvement Committee." There is no evidence that the hospital was reviewing grievances through their Quality Improvement Committee.

Based on review of hospital policy and procedure, Governing Body meeting minutes and interview it was determined the hospital failed to correctly identify grievances, and failed to ensure all grievances are reviewed by the Governing Body or a committee appointed by the Governing Body. This occurred in four of five grievances reviewed. (#37, 38, 39, and #40)
Findings:
1. A hospital policy, "Patient Grievance Policy and Procedure" documented, "...results identifying an opportunity to improve care will be reviewed by the Quality Improvement Committee, results from the Quality Improvement committee will be report to the medical staff, the governing board will review and approve this patient grievance process at least once every other year." There is no evidence that grievances are reviewed through the governing body or a committee appointed by the governing body. There is no evidence that the facility uses grievances to improve patient care.
2. Four of five (# 37, 38, 39, and #40) grievances reviewed showed no evidence of review through the governing body.
3. One of five (#41) included a letter that showed review from the governing body.
4. On the afternoon of 09-03-2013 the compliance officer was asked if she could provide further documentation on investigation of grievances. She said she didn't have anything else and stated "We don't get many complaints".

Based on review of hospital grievances, and policy and procedures, and an interview, it was determined the hospital failed to provide patients with a written notice of decision and steps taken to investigate the grievance. This occurred in five of five grievances reviewed. (# 37, 38, 39, 40, and 41).
Findings:
1. A hospital policy, titled, "Patient Grievance Policy and Procedure" documented, "the patient or representative will be informed in writing of the findings of the investigation, as well as any corrective actions recommended within 7 days of receiving the complaint."
2. Two of the grievances (#39, and #41) were followed with a letter stating "thank you for taking the time to provide us feedback ... Your case has been reviewed by the Medical Staff." The letter does not mention steps and actions taken to resolve the grievance.
3. Three of the five grievances (#37, 38 and #40) had no initial letter or follow up letter sent to the complainant.
4. The compliance officer was asked why all five grievances did not have a letter sent and she stated that 2 of the complaints were not official (#37 and #38). One of these 2 (#37) complaints was presented to the compliance officer by the patient in person.

Based on policy and procedure review and interview the hospital failed to ensure that a policy and procedure for abuse was in place on the medical - surgical unit.
Findings:
1. The hospital administrative staff was asked to provide the hospital's abuse policy. A binder titled Nursing policy and procedures was provided. There was no abuse policy in the policy and procedure binder.
2. On 09-03-2013 at 1045 the hospital administrative staff was asked to provide the hospital ' s abuse policy. The Director of Nurses brought the surveyors an abuse policy that was labeled as an abuse policy for the Emergency Department. The Director of Nurses stated that they do not have an abuse policy in the Nursing policy and procedure book for the medical - surgical unit.
3. On 09-05-2013 upon exit, the Director of Nurses verified that there is no policy and procedure on abuse for the medical - surgical unit.

Based on review of patient medical records, hospital documents and staff interview, the hospital failed to develop a death reporting policy that addressed the requirements of reporting to CMS (Centers for Medicare and Medicaid Services) and the documentation required.

Findings:

On 9/3/13 Staff B stated the hospital had no deaths in restraints.

Review of Patient #3's medical record documented the patient had expired while right and left soft wrist restraints were in use. This was confirmed by Staff A in the afternoon of 9/4/13.

On 9/4/13 at 3:55 the surveyors requested the hospitals internal tracking log for deaths in soft restraints. None was provided. Staff A confirmed the hospital did not track deaths in restraints.

The restraint and seclusion policy did not provide guidance to staff regarding the requirements of reporting restraint deaths to CMS and charting the information with date and time in the patient's medical record.

Based on review of hospital documents, personnel files, medical records and interviews with hospital staff, the hospital failed to ensure nursing staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas and are competent to provide care to meet the needs of the patients. Review of nine of nine nursing staff (G, N, T, P, GG, JJ, OO, W and V) who provided care in specialty areas and whose personnel files were reviewed did not have current job specific competencies.

Findings:

The hospital is an acute care hospital that cares for patients of all ages in the emergency, surgical and inpatient settings.


1. Staff G, who was the case manager, did not have any training and competencies for the case management position.

2. Review of Staff N's personnel file did not have any documentation of hospital orientation or competencies in the education file. Staff A was asked for evidence of hospital training and orientation for Staff N. None was provided.

3. Review of Staff OO's and P's personnel files did not contain evidence of scrub technologist competencies in their education file, with the exception of endoscope reprocessing.

4. Staff T, designated as the Operating Room (OR) Manager, did not have orientation and documented competencies for peri-operative duties, pre-operative,circulating and post-operative/recovery nurse and OR manager.

5. Staff JJ, designated as the Infection Control Nurse, also worked the surgery department. Staff JJ's personnel file did not contain evidence Staff JJ had been trained or showed competency for peri-operative duties. The file did not contain evidence Staff JJ had prior surgery experience. The file did not contain competency testing or a job description for infection control.

6. Staff V worked as the pharmacy room manager, Staff V did not have orientation and training to the drug room by the pharmacist.

7. Staff W, worked as the pharmacy tech, did not have orientation and training to the drug room by the pharmacist.

8. Staff GG, who provided respiratory treatments, did not have competencies and training for respiratory therapy by the respiratory therapist.

Based on record review and staff interview, it was determined the facility failed to ensure non-employee nursing personnel were oriented to hospital policies and procedures and their clinical activities were evaluated at least yearly.

Findings:

On 09/4/13, the personnel record for agency nurse N was reviewed. The record did not have documentation of orientation to hospital-specific policies and procedures and documentation of verified competency to perform clinical activities.

Staff A was asked for evidence of hospital orientation and training. None was provided.

Based on medical record review and interviews with hospital staff, the hospital does not ensure that all entries in the medical record:

a. Contain the date and time when they were signed or authenticated in electronic form by the person responsible for the services provided. This occurred in eight of eight (Records #1 through 8) medical records reviewed.

b. Contains complete entries. This occurred for six of six medical records (Records #15, 16, 27, 28, 29, and 30) of patients who had endoscopic procedures and whose records were reviewed.

Findings:

On 9/6/13, Staff I stated the hospital had converted to electronic medical records (EMR) in June 2012.

1. Staff I was asked if Medical Record's policies and procedures included policies for EMR. Staff I told surveyors no. There were no policies and procedures developed, reviewed, approved and implemented stipulating all required elements for inpatient and outpatient EMR. There were no policies and procedures developed, reviewed, approved and implemented indicating how to access a complete EMR for inpatients and outpatients. There were no policies indicating what documents comprised a complete outpatient record or a complete inpatient record. There were no policies on documentation standards including processes used to document in the EMR. There were no policies indicating integration of paper medical records into the EMR. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

Medical records (#4 and 5) contained an electronic document, titled, "Conscious Sedation Monitoring Record," that did not contain authentication by the author. This was confirmed by Staff I on 9/6/13.

Medical records (#1, 4 through 6) contained preprinted Standing Orders for Staff BB that did not have the date and time the orders were written by the physician or licensed practitioner.

Medical records (#2, 5 and 6) contained preprinted Standing Orders for Staff BB that did not have the time the orders were written by the physician or licensed practitioner.

Medical records (#2 through 6 and 8) contained preprinted Admission orders that did not have the time the orders were written by the physician or licensed practitioner.

Medical records (#3 through 5) contained preprinted Insulin orders that did not have the date and time the orders were written by the physician or licensed practitioner.

The findings were reviewed with administrative staff on the afternoon of 9/5/13.

2. The interoperative records for the six patients mentioned above did not contain the names of all persons present during the procedure and their functions/jobs. Only the name of the staff administering conscious sedation was documented.

This findings was reviewed and verified with Staff T on the afternoon of 09/05/13.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure the drug room and other medication storage areas are administered in accordance with accepted professional principles. All drugs are not mixed and dispensed by a licensed pharmacist or pharmacy-supervised personnel. One (W) of one pharmacy staff was observed mixing multiple intravenous antibiotic piggybacks under a laminar flow hood for patients in the hospital. There was no pharmacist on site for supervision. The repackaging log did not have evidence of pharmacist review of drugs that were repackaged from the original bottle by pharmacy staff before being administered to patients.

Findings:

1. On 09/03/13 in the afternoon, Staff W, who was not a pharmacist, was observed mixing and labeling five intravenous (IV) antibiotics in a laminar flow hood in the hospital drug room for administration to hospital patients. There was no pharmacist available to certify these IV's before they were administered to patients.

2. Drug room staff said that they had been mixing drugs in the same manner without pharmacist supervision ever since the full time pharmacist left.

3. The hospital is not a licensed hospital pharmacy with a full time pharmacist. The hospital is a licensed drug room with a consultant pharmacist who is present at the hospital, according to staff, about 5 hours a week. The drug room is staffed with one part-time registered nurse, the drug room manager (supervisor), who is a licensed practical nurse (LPN) and a pharmacy tech who also is a LPN.

Based on record review and interviews with hospital staff, the hospital does not ensure the consultant pharmacist supervises and evaluates the performance and competency of pharmacy personnel who provide pharmacy services when the Consultant Pharmacist/Pharmacist in Charge is not on the premises. Two (V and W) of two pharmacy/drug room personnel files reviewed did not have evidence of competency evaluations and orientation specifically for the pharmacy/drug room by the Consultant Pharmacist/Pharmacist in Charge. Staff W was performing dispensing duties without the supervision of the pharmacist as required by State and Federal standards of practice.

Findings:

1. Staff V designated as the Drug Room Supervisor/Pharmacy department manager and Staff W designated as a Pharmacy Tech did not have competency evaluations and orientation by the Consultant Pharmacist specific for the duties they performed in the Drug Room Pharmacist/Pharmacist in Charge. They only had general hospital and nursing orientation. This was signed by the previous pharmacy manager who was a nurse.

2. Drug room staff said that they had been mixing drugs in the same manner without pharmacist supervision ever since the full time pharmacist left. The present Consultant Pharmacist/Pharmacist in Charge had been on contract since January 2013.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure all compounding, packaging and dispensing of drugs are under the supervision of a pharmacist and performed consistent with State and Federal laws. Intravenous antibiotics are not prepared by a licensed pharmacist or under the supervision of a licensed pharmacist and drugs repackaged by a non-pharmacist did not have evidence of a pharmacist review before being dispensed to patients.

Findings:

1. Staff W, who was not a pharmacist, was observed mixing five (5) intravenous (IV) antibiotic piggybacks in a laminar flow hood for patients in the hospital. There was no pharmacist available on site for supervision.

2. The drug repackaging log did not have evidence of a Pharmacist in Charge (PIC) signature or initials showing review of the repackaged drugs before being dispensed to patients. The only signature/initials on each drug repackaged was Staff W's who is not a pharmacist.

3. The drug repackaging log documented that Versed 5mg/ml (milligrams/milliliters)was drawn up by Staff W into several 1ml syringes for use in surgery. This was verified on 09/03/13 in the morning by drug room staff. The log only had Staff W's initials on the log. There were no initials/signature of pharmacist review before the syringes were dispensed for patient use.

4. The hospital does not have a licensed pharmacy with a full time pharmacist. The hospital has a licensed drug room with a consultant pharmacist who is present at the hospital, according to staff, about five (5) hours a week. The drug room is staffed with one part-time registered nurse, the drug room manager (supervisor), who is a licensed practical nurse (LPN) and a pharmacy tech who also is a LPN.

5. Drug room staff said that they had been mixing drugs in the same manner without pharmacist supervision ever since the full time pharmacist left.

Based on review of radiology personnel files, staff interview and the radiology policy and procedures, the facility failed to have only qualified personnel designated by the radiologist in charge and/or the medical staff use radiology equipment and administer procedures. There was no documentation in the radiology personnel file that the radiologist/medical staff had reviewed equipment, technique, shielding, and radiation safety requirements and determined that staff was qualified to operate specific equipment.

Findings:

Review of a hospital policy, titled, " Departmental Orientation Imaging Services, " documented, " ...Personnel will then attend orientation to the Imaging Services Department under the supervision of the Imaging Service Manager ... "

Review of Staff L ' s personnel file did not contain evidence of orientation to the radiology department.

On 9/3/13 at 2:09 Staff D stated she did not have any documentation of department specific orientation per the hospital policy.

Based on observation, staff interview, and policy and procedure review, it was determined the hospital failed to handle and store trash and biohazardous waste generated in the hospital as required by regulation.

Findings:

The infection control (IC) policy for housekeeping required, "... The enclosed storage area for biohazard containers or bags should be kept clean of debris, locked and secured when unattended..."

The biohazard barn was observed to be unlocked on all three days of the survey (09/03, 04, and 05/13).

The above findings were presented in the exit conference with administration. No further documentation was provided.

Based on review of documents and interviews with staff, the hospital failed to enforce fire control plans and conduct fire drills for the entire hospital. The hospital did not conduct hospital-wide fire drills at unexpected times at least quarterly on each shift.

Findings:

1. Fire drills were separately conducted on the Department of Corrections and the community side of the hospital.

2. The surgical services has started using alcohol as part of some surgical scrubs. No evidence was provided to show staff had been trained and conducted drills for surgical fires. At the time of surveyor tour and observation on the afternoon of 09/03/13, a large multi-use container of alcohol was being stored in the operating room.

3. These findings were confirmed with staff at the time of review on 09/03/13.

Based on review of hospital documents, surveyor observations and hospital staff interviews, the hospital failed to provide and maintain a safe and sanitary environment to protect patients.

Findings:

1. The community-side patient rooms have roller latches on the doors. these doors would not remain closed in case of fire and/or smoke.

2. The smoke evacuation system in the operating room was not tested on the annual fire safety test conducted March 3, 2013.

3. The hospital does not maintain corridors and egresses from obstruction.
a. Four computers-on-wheels were staged in the main corridor of the Department of Corrections inpatient unit.
b. A blue four-wheeled soiled holding cart was left out in the hallway throughout the day on 09/03/13 next to the surgery entrance.

4. The hospital's pharmacy drug room was moved to another location without ensuring it met the requirements. The current drug room does not have a hand-washing sink.

5. The endoscope decontamination/processing room had no clear designation or segregation between "clean" and "dirty" processing. There was no flow from the contaminated area to the clean area. The room is not designed to ensure contamination does not occur. Although the room had two (2) sinks, they were not remote from each other. The sinks were next to an open hopper/"nurse's sink" When Staff T recited the procedure for cleaning scopes, she told the surveyors that the sinks were not disinfected between initial washing of the scopes and the clean rinse. The disinfectant agent used in this area was not effective against C-difficile.

6. In the central sterile room, there was no separation between dirty/contaminated instruments and clean instruments. Dirty instruments were brought into and cleaned in the same room as clean instruments are wrapped, sterilized and stored. The sink used to wash the dirty instruments is next to a storage rack that contain sterile instruments pulled to use in surgical cases. The ventilation requirements are different for clean and dirty.

7. The surgical supply room had clean and sterile supplies were stored in the same room as the hospital's ultrasonic instrument cleaner was used.

8. At the time of the surveyors tour on the afternoon of 09/03/13, a multi-use container of alcohol used for surgical scrubs was kept in the operating room. This is a safety/fire hazard.

Based on observation, interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing program to:
a. Prevent, control, and investigate infections and communicable diseases and

b. Provide a sanitary environment to minimize infections and communicable diseases in patients and staff.

Findings:

1. The hospital failed to maintain a sanitary and safe environment.

The disinfectants used throughout the hospital have not been reviewed and approved by the hospital's Infection Control committee through the quality program and the products observed and identified by staff as the one they would use in the endoscopy suite is not effective against Clostridium difficile (C-diff). (Refer to Tag A-749)

3. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

4. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases between patients and staff.

5. Leadership does not ensure infection control concerns and issues are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

Based on observation, review of infection control data, surveillance activities, personal files, meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained an ongoing comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

The hospital does not have an ongoing infection control/prevention (IC) program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained.

Findings:

Program:
1. The hospital IC program had not performed a hospital risk assessment to determine what organisms are most likely to occur in the hospital and what organisms are most likely to be present in the community. This was confirmed by Staff JJ, staff identified as responsible for infection control (ICP), on the afternoon of 09/05/13.

2. The hospital IC program had not developed a system to ensure appropriate infection control procedures were developed and followed in each department of the hospital.

3. The hospital IC program, titled "Scope of Care", with a revised date of January 2010, recorded, "...Hospital-wide surveillance is planned through an annual calendar..." On 09/05/13 at 1640, Staff JJ stated the hospital did not have an annual surveillance calendar. She stated she had not developed one.


Disinfectant:
1. The prevalent disinfectant available for use throughout the hospital (community inpatient unit, emergency room, surgery areas and housekeeping cart), PDI Super Sani-Cloth wipes (purple top), is not effective against Clostridium difficile (C-diff of C-difficile).

2. Nursing staff interviewed pointed to the purple top wipes and told the surveyor that they would use the above product to clean.

3. On the afternoon of 09/05/13, housekeeping staff, MM, told the surveyor that if she was told a patient had C-diff, housekeeping would make up a fresh dilution of bleach to disinfect the room and equipment on the community side, but would use the bleach wipes on the Department of Corrections side. She told the surveyor that neither the bleach wipes nor concentrated bleach was kept on the housekeeping cart.

4. The only department/unit with bleach disinfectant available for immediate use was the Department of Corrections unit. This was a canister of commercially prepared bleach wipes, Clorox Healthcare Bleach wipes.

5. The surveyor requested to review the purchasing order for the bleach disinfectants. Only one purchasing requisition was provided. The date was March 2013 and was for 12 individual containers.

6. The hospital's IC committee has not reviewed and approved the disinfectants available in the hospital.


Surveillance/Monitoring:

At the time of entrance to the hospital, the surveyors requested infection control documentation, including "all surveillance/monitoring activities" for the past 12 months. This request was repeated twice on 08/27/13. The surveyor reviewed all data presented.

Review of infection control surveillance/monitoring data did not show the infection control monitored all departments and units to ensure compliance with established hospital policies and procedure and standards of practice to maintain a safe and sanitary environment, including, but not limited to:

1. Surgical Services:
a. There was no oversight and monitoring of flash sterilization practices. The surveyor reviewed the autoclave envelopes. According to the review, flash sterilization loads did not document a patient name associated with the flashed item and there was no documentation of the reason for flashing.
b. Routine sterilization was not reviewed or monitored for adequate cycles.
c. Routine endoscope processing was not reviewed for adequate processing. Although the ICP documented reprocessing observation on 04/15/13 and 05/12/13, no notation or inappropriate/inadequate space/facilities or change in process or cleaning space had been implemented.
d. Surveillance of cleaning and disinfecting practices were not monitored.
e. There was no monitoring of clean storage.

2. Environmental Services:
Only two environmental rounds for 2013 were provided. These were a "walk through" review of only the kitchen area, not a hospital wide review. The review did not indicate the observer monitored the application of disinfectant to ensure the employee followed manufacture guidelines for effectiveness.

3. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines,
b. Isolation carts are stocked appropriately,
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements,
d. Appropriate disinfection of the room occurs.

4. There is no monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are mixed/diluted, applied and remain "wet" contact time according to the manufacturers guidelines.

5. The ICP did not monitor and track staff illness to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

6. The ICP did not monitor staff immunizations to ensure the personnel files were up to date and staff immunizations reflected those required by Oklahoma State Hospital Licensure Standards and recommended by Centers for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP). Physician, allied health, and contract staff files were not complete.


Observations:
1. Biohazard barn/shed was not locked for the 3 days of the survey (09/03, 04 and 05/13). The IC policy for housekeeping required, "... The enclosed storage area for biohazard containers or bags should be kept clean of debris, locked and secured when unattended..."

2. On 09/03/13, a tour was conducted of the surgical areas. The following observations were made on that date, unless otherwise noted:

Endoscopic Procedure Room:
When ask, on the afternoon of 09/03/13, what disinfectant was used, Staff T told the surveyors the only product used was the PDI Super Sani-Cloth wipes (purple top). The most prevalent organism for colonoscopies is C-diff. The product is not effective against C-diff.

Endoscope Processing Room
The endoscope decontamination/processing room had no clear designation or segregation between "clean" and "dirty" processing. There was no flow from the contaminated area to the clean area. The room is not designed to ensure contamination does not occur. Although the room had two (2) sinks, they were not remote from each other. The sinks were next to an open hopper/"nurse's sink" When Staff T recited the procedure for cleaning scopes, she told the surveyors that the sinks were not disinfected between initial washing of the scopes and the clean rinse. The disinfectant agent used in this area was not effective against C-difficile.

Central Sterile Room:
There was no separation between dirty/contaminated instruments and clean instruments. Dirty instruments were brought into and cleaned in the same room as clean instruments are wrapped, sterilized and stored. The sink used to wash the dirty instruments is next to a storage rack that contained sterile instruments pulled to use in surgical cases. The ventilation requirements are different for clean and dirty.

Surgical Supply Room:
Clean and sterile supplies were stored in the same room as the hospital's ultrasonic instrument cleaner was used.

Surgery Suite:
On 09/04/13 the surveyors observed Staff Z remove gloves and proceed to other patient care activities without performing hand hygiene.

3. The Pharmacy Drug Room did not have a hand washing sink.

4. As previously stated the only disinfectant, other that observation on the Department of Corrections unit, available for use in the hospital was the PDI Super Sani-Cloth wipes (purple top)

The Center for Disease Control and Prevention guidelines, regarding possible C-diff encounter, documented patient care areas need to be cleaned thoroughly with an EPA registered sporicidal agent. The EPA registered purple top PDI wipes do not kill the Clostridium difficile spores indicated directly on the manufacture's label.


Meeting Minutes:
Hospital meeting minutes provided to the surveyors during the on-site survey containing infection control data and reviewed were: quality assessment and performance improvement (QAPI), medical staff, governing body, and the meeting minutes that the surveyors were told were Infection Control Committee meeting minutes.

1. On the afternoon of 09/05/13 , the ICP told the surveyors that the disinfectants had been reviewed and approved in the meeting minutes. Review of the meeting minutes for the past 12 months did not demonstrate this had occurred. Staff JJ stated they were approved in the Safety Committee meeting minutes. The Safety Committee meeting minutes for 04/15/13 was provided to the surveyor. The only disinfectant mention in the minutes was the need for bleach products to kill C-diff. There was no other mention of any other disinfectants used in the hospital and this was not brought before the Infection Control Committee or any other meeting minutes reviewed.

2. The meeting minutes reviewed concerning infection control did not demonstrate review and analysis of patient and staff illnesses to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

3. The meeting minutes did not demonstrate immunization histories were reviewed and discussed. Review of contract dietitian's file and five of seven credentialed physician and allied health files did not contain complete immunization histories as required by Oklahoma State Hospital Licensure Standards and recommended by Centers for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP).

4. The meeting minutes did not demonstrate review and analysis of staff exposures with review to ensure OSHA (Occupational Safety and Health Administration) guidelines were followed.

5. The meeting minutes did not demonstrate that any of the observations or problems identified by the surveyors had been identified or reviewed for compliance.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement (QAPI) committee and:

1. Were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Hospital meeting minutes provided to the surveyors during the on-site survey containing infection control data, QAPI, medical staff, governing body, and the meeting minutes that the surveyors were told were Infection Control Committee meeting minutes, did not contain evidence/demonstrate the hospital leadership:
a. Reviewed and analyzed infection control data or lack thereof;
b. Ensured that all departments/units of the hospital were included and monitored through the infection control/prevention program;
c. Ensured infection control/prevention policies and procedures were developed, implemented and followed to ensure a safe and sanitary environment and that staff were inserviced on those policies;
d. Developed corrective plans of action to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases; and
e. Provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

2. The same hospital minutes did not contain review and analysis of employee immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff. The hospital's leadership failed to ensure employee exposures were followed as part of the infection control program. Meeting minutes did not demonstrate the incidents were analyzed or provision of corrective actions considered to reduce exposures.

3. Meeting minutes did not contain evidence the hospital's leadership has ensured policies and procedure were developed for all areas of the hospital concerning current accepted standards of practice in infection control.

4. The hospital offers surgical services, including endoscopy procedures. The infection control portion of the meeting minutes did not demonstrate surgical services was monitored by infection control. The minutes did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice (Refer to Tags A 749 for details).

5. The hospital's leadership has not provided oversite of the infection control program to ensure a safe environment. With the exception of respiratory isolation Fit testing, the meeting minutes did not reflect the hospital's leadership ensured ongoing surveillance/monitoring of all areas was performed to ensure current standards of practice in infection control were followed. This included, but not limited to:
a. Hand hygiene;
b. Isolation practices;
c. Disinfectant practices;
d. Instrument and equipment cleaning practices;
e. Sterilization practices;
f. Environmental process inspections.

Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in accordance with acceptable standards of practice.

Findings:

1. There is no documentation staff designated as perioperative personnel have education, training, and competency in perioperative services. (Refer to Tag A-397, findings #3, 4 and 5, and Tag A-942).

2. Meeting minutes concerning infection control and surgery services for 2013 did not include any surveillance for the Operating Room, other that one scope reprocessing verification. There is no documentation the Infection Control Program reviews and analyzes sterilization practices, hand hygiene, or any infection control practices in the perioperative suite. Staff T told the surveyors on 09/03/13 that they would use the purple top, PDI Super Sani-Cloth, wipes between all surgery and endoscopic procedures. This product is not effective against Clostridium difficile (C-diff). (Refer to Tag A-749).

3. Review of Quality Assurance Performance Improvement does not include specific indicators designated for Surgical Services, other than the statement that there was no surgical site infections. There was no documentation the facility collected, reviewed and analyzed data in relation to quality assurance and performance improvement to ensure surgical services were provided in a safe and sanitary environment.

4. Intraoperative endoscope procedure records do not contain documentation of all staff present during the procedure. Only the name of the staff administering moderate/conscious sedation is documented.

5. Shorten cycle/Flash sterilization cycles did not contain the reason for the shortened cycle or the name of the patient, if not the manufacturer's specified method of sterilization. The hospital's Flash policy did not specify what was to be detailed on the log. (Refer to Tag A-951).

6. The hospital does not have a policy and procedure for Time Out. (Refer to Tag A-951).

7. The hospital is now using alcohol as part of some surgical scrubs. At the time of the initial surveyors' tour of the surgical area on the afternoon of 09/03/13, a large previously opened multi-use container of alcohol was observed in the operating room. The fire safety/risk had not been communicated to staff. No fire drills in the surgical suites had been conducted. Meeting minutes did not reflect the hospital had considered smaller individual use contained that would only be brought into the operating room when needed.

Based on review of personnel files and hospital documents and interviews with hospital staff, the hospital failed to ensure the surgery department supervisor was trained, competent and experienced.

Findings:

1. Staff T told the surveyors on 09/03/13 that she had been at the hospital since August of 2003 and was trained by the previous surgery manager.

2. Review of Staff T's personnel file did not contain evidence of surgical training and competency or previous surgery experience. The file did not contain evidence Staff T had received ongoing training or attended any meetings or education on current surgery standards of practice.

3. Staff T's personnel file did not contain a job description for surgery department supervisor/manager. The surgery policies and procedures manual did not contain job descriptions for any of the surgery positions.

4. The above findings were reviewed during the exit conference on 09/05/13. The hospital was given the opportunity to provide additional information. None was provided.

Based on review of policies and procedures and medical records and staff interviews, the hospital failed to ensure the surgical services policies were developed according to national standards of practice and were enforced to ensure patient safety.

Findings:

1. The hospital did not have a policy requiring a "Time Out" procedure to be performed to confirm the correct patient, surgical site and procedure have been identified, and that all required documents and equipment are available and ready for use, with stipulation of the required disciplines to participate in the "time out" process. This was confirmed with Staff T on the afternoon of 09/03/13.

2. The policy and procedure for shortened/Flash sterilization cycles did not detail the requirement that reason for the cycle use and the name of the patient that the instrument was used (if applicable). Review of the autoclave logs did not contain this information. On the afternoon of 09/04/13, Staff OO stated she did not know to put this information on the log.

3. The hospital did not have a policy and procedure to require the interoperative endoscope procedure records contained documentation of all staff present during the procedure. Review of endocopic procedure medical records showed only the name of the staff administering moderate/conscious sedation is documented on the interoperative portion of the medical records. This finding was reviewed with Staff T on the afternoon of 09/05/13.

4. The hospital did not have a policy and procedure requiring the endoscopy procedure and processing rooms to be cleaned/disinfected after each use with a disinfectant effective against Clostridium difficile (C-diff). C-diff has been proven to be the most prevalent organism for these types of procedures.
The Center for Disease Control and Prevention guidelines, regarding possible C-diff encounter, documented patient care areas need to be cleaned thoroughly with an EPA registered sporicidal agent.

5. The policy and procedure manual did not contain job descriptions detailing the requirements for scrub and circulating staff, with the duties and responsibilities.

6. The policy and procedure manual did not contain a scope of surgical procedures that could be performed at the hospital.

Based on review of patient records, review of personnel files and interview, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. This occurred in 1 of 20 records reviewed where nursing staff administered nebulizer treatments to patients.

Findings:

1. On the afternoon of 09-03-2013 the department manager of the respiratory therapy department stated that the respiratory therapists do all of the respiratory therapy procedures and that respiratory therapy services are available 24 hours a day and 7 days a week.
2. Review of patient record #14, showed that a nebulizer breathing treatment was performed by the nursing staff on 2 occasions.
3. Staff II stated that respiratory therapy staff is always in the building and on the day shift they do all the respiratory therapy procedures but that nursing staff that work the night shift are trained to perform nebulizer breathing treatments.
4. Staff HH stated that most of the time respiratory therapy staff is in the building but sometimes the nursing staff does perform nebulizer breathing treatments. Staff HH stated that she had been trained by other nursing personnel to perform nebulizer breathing treatments.
5. On the afternoon of 09-05-2013 upon exit, the Director of Nurses verified that the nursing staff does provide nebulizer breathing treatments.
6. Eight of Eight nursing personnel files reviewed did not contain respiratory competency training and verification completed by the respiratory therapist.